How Often Do Psychiatrists Provide Psychotherapy?

Until about 25 years ago, psychiatrists were often viewed as psychotherapists who also could prescribe medications because they were physicians. As more treatments for psychiatric illnesses have become available, that perception has evolved. What percentage of psychiatrists currently focus their efforts on administering extended psychotherapy sessions? A study recently published in the American Journal of Psychiatry by Daniel Tadmon and Mark Olfson examines “Trends in Outpatient Psychotherapy Provision by U.S. Psychiatrists: 1996-2016.”

These investigators examined data from the National Ambulatory Medical Care Survey. This is an annual survey conducted by the Centers for Disease Control and Prevention (CDC) to obtain “a nationally representative sample of outpatient visits to non-federally funded and non-hospital-based physicians’ practices.” The survey instrument defines psychotherapy as the intentional administration of verbal techniques targeting a person’s emotional life in order to reduce symptoms. In their study, Tadmon and Olfson only included visits in which the patient saw a psychiatrist, and they excluded telehealth and other types of non-office visits. In addition, they restricted their definition of psychotherapy to sessions that were longer than 30 minutes.

What did the study demonstrate? The researchers found that the percentage of psychiatrist visits involving psychotherapy lasting more than 30 minutes decreased steadily from 1996 to 2016. For the bulk of their analyses, the investigators divided the data into three 7-year intervals: 1996–2002, 2003–2009, and 2010–2016. They found that the percentage of psychiatrists who administered no psychotherapy sessions lasting longer than 30 minutes increased from 27% during 1996–2002 to 53% during 2010–2016. On the other hand, the percentage of psychiatrists administering psychotherapy during all patient visits lasting over 30 minutes remained relatively stable during the three time intervals (11–15%). Those who specialized in providing psychotherapy prescribed medications to about 66% of their patients. Those who did not specialize in extended therapy sessions prescribed medications for over 90% of their patients.

Psychiatrists who specialized in providing psychotherapy tended to treat patients with dysthymia (long-lasting, mild depressive symptoms), anxiety disorders, and personality disorders. Many of their patients had the resources to self-pay, i.e., they paid the psychiatrists’ fees out of pocket.

The psychiatrists who did not provide psychotherapy during sessions lasting more than 30 minutes were more likely to treat individuals with severe psychiatric disorders, including bipolar disorder, schizophrenia, and major depressive disorders. Those psychiatrists providing fewer psychotherapy visits were more likely to accept insurance for their services and less likely to require patients to pay out of pocket.

There are several issues related to this discussion that are important to consider: First, there is a critical shortage of psychiatrists at a time when there is increasing demand for psychiatric care. Second, psychotherapeutic techniques are often utilized by psychiatrists during visits lasting 30 minutes or less. Finally, non-physician mental health professionals trained in administering evidence-based psychotherapies often work with psychiatrists, and such teamwork allows patients to receive formal psychotherapies in a cost-efficient manner. This latter point is complicated by the fact that there is also a shortage of non-physician psychotherapists with formal training in evidence-based psychotherapies, including cognitive behavioral therapy (CBT) and interpersonal therapy (IPT).

The field of psychiatry is rapidly changing. Advances in neurosciences, neuroimaging, genetics, and psychopharmacology are leading to innovative therapeutic approaches administered by psychiatrists. Psychotherapeutic advances are also being made, and these often can be implemented by non-physician mental health professionals. Although psychiatrists should continue to be familiar with psychotherapeutic advances in order to work with non-physician mental health professionals in providing the best care for patients, they are increasingly focusing their attention on treatments that require their medical background to implement.

The data described in this paper demonstrate the speed at which this evolution is occurring. Some in the psychiatric field are wary of these trends and believe the administration of extended sessions of psychotherapy is fundamental to the identity of psychiatrists. Others are excited by the evolving identity of psychiatrists as clinical neuroscientists who specialize in treating patients with severe disorders utilizing a variety of treatments, including psychotherapies, and who work collaboratively with non-physician mental health clinicians.

This post was written by Eugene Rubin MD, Ph.D., and Charles Zorumski, MD.